Social Determinants of Health:
10 Major Points
Presentation for Academy Health Meeting
June 2009
Stephanie Robert, Ph.D.
University of Wisconsin-Madison
sarobert@wisc.edu
What are social determinants of health?
“The social determinants of health are the conditions
in which people are born, grow, live, work and age,
including the health system. These circumstances are
shaped by the distribution of money, power and
resources at global, national and local levels, which
are themselves influenced by policy choices. The
social determinants of health are mostly responsible
for health inequities - the unfair and avoidable
differences in health status seen within and between
countries.”
- WHO Commission on Social Determinants of Health

#1: Health care is only one of many factors that
affect health.
Health care is only one of many factors that affect
health and well-being…
Social
Environment
Individual
Response
Behavior
Biology
Physical
Environment
Health &
Function
Well-Being
Disease
Genetic
Endowment
Health
Care
Prosperity
SOURCE: R.G. Evans & G.L. Stoddart (1990). “Predicting Health, Consuming Health
Care,” Social Science & Medicine.
From the WHO Commission on Social Determinants of Health

#2 Although individual health behaviors
matter to health, not everyone has an equal
opportunity to make healthy lifestyle choices.
four-hour documentary series produced by California
Newsreel with Vital Pictures, Inc.


Chaired by Alice Rivlin and Mark McClellan
2009 report identified non-medical strategies to
improve the health of all Americans
“Beyond Health Care: New Directions to a Healthier
America”.

#3 Socioeconomic status disparities in health
are strong and persistent.

#3 Socioeconomic status disparities in health are
strong and persistent.




They exist in all countries, they are wide and persistent over
time, and they are widening in the U.S.
Reciprocal causality: health
SES
Income, education, wealth, and occupation each have
separate effects on health
SES has complex, cumulative effects over the life course


e.g., Education has strongest effects on the onset of disease
Income has strongest effects on the progression of disease
(Herd et al., 2007)

#4 The relationship between SES and health is
characterized by a gradient relationship, but it is
still those at the bottom of the SES scale who
suffer disproportionately.
UK: Whitehall Study of Civil
Servants
Relative Risk of Mortality from CD Over 25 Yrs
1.9
1.7
1.8
1.5
1.6
1.3
1.1
1.3
0.9
0.7
1
0.5
Admin
Prof/Exec
Clerical
Other

#5 Many psychosocial factors are strongly
linked to health, particularly quantity and
quality of social support, sense of control, and
stress.
Highlighted Social
Determinants Of Health
• Socioeconomic status
• Stress
• Early life factors
• Social exclusion
• Workplace factors
• Unemployment
• Social support
• Addiction
• Food
• Transportation
2003. Edited by Richard Wilkinson and Michael Marmot
For the World Health Organization
New WHO
Report
August 2008
Health equity through action
on the social determinants
of health

#6 Neighborhood and other geographic
contexts matter to health.
Neighborhood context affects health

Physical Environment


Social Environment


Housing conditions, air, water, and land quality, safe
recreational space
Exposure to crime and violence, social networks and
supports, community norms and values
Service Environment

Health and social services, transportation, grocery
stores, job opportunities, quality education

#7 Racial/ethnic disparities in health are
strong and persistent. They exist both through
and independent of SES disparities in health.
Infant Death Rates by Mother’s Education, 1995
20.0
Deaths per 1,000 population
18.0
16.0
14.0
12.0
White
Black
10.0
8.0
6.0
4.0
2.0
0.0
<High School
High School
Some College
Education
College grad. +
(Health United States, 1998)

#8 Racial disparities in residential segregation
and racial discrimination can have effects on
access to quality medical care (see Unequal
Treatment) and exposure to material and
psychosocial conditions that affect health.
Examples of racism mechanisms




Institutional and individual discrimination affect
educational, occupational, and economic
attainment
Racial residential segregation affects access to
resources and exposure to unhealthy residential
conditions.
Institutional and individual discrimination affect
access to health-promoting goods and services
Perceived racism is a psychosocial stressor that
impacts health.

#9 Often interventions can actually worsen
racial and socioeconomic inequalities in health,
as the most advantaged are more rapidly able
to take advantage of knowledge, resources, and
technology.
Mortality at Titanic
by passenger class, women and children
80
Women
Mortality (%)
70
Children
60
50
40
30
20
10
0
1st
2nd
3rd
.
Passenger class
From Broom L & Selznick P, 1968
1st/2nd
3rd
Landing in the Hudson

#10 Social policy is health policy.
End